​The inspiring community and research work that the Institute for Life Course Health Research (ILCHR) does resonates with the vision of SU's Faculty of Medicine and Health Sciences to enhance health and health equity with and for the communities it serves.

 The institute, based in the Department of Global Health and led by Prof Mark Tomlinson and Prof Sarah Skeen, conducts research on infant, child, adolescent, maternal and family well-being, health and development in low resource communities.

“We are interested in testing solutions and doing three things," Tomlinson said. “We want to deliver cutting-edge research that prioritises the well-being of children, adolescents, families and people across the life course; work with communities to develop interventions; and share the knowledge that we generate as effectively and as broadly as possible."

 “Underlying all of this is a commitment to being part of the solution to the deep and profound inequality that exists," he adds.

 The ILCHR works throughout South Africa, with research teams based in Khayelitsha in the Western Cape and the OR Tambo district in the Eastern Cape. They also run projects across Africa and South Asia, and collaborate with international agencies such as the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) on programmes on nurturing care to improve early child development, maternal and child health, child and adolescent mental health and development, and maternal mental health.

Early events, later repercussions

It is now widely recognised that events in utero and in early childhood have long-term health impacts. Research has revealed the developmental vulnerability of a child in the first 1 000 days of life (conception to two years), especially in terms of neurodevelopment. Intergenerational factors are also significant. Tomlinson explains: “We're starting to realise that one predictor of an infant's growth is the grandmother's nutritional status. And that a young woman's health – her nutrition, whether she's getting regular medical check-ups – is key in the health of the baby she's not even pregnant with yet."

This is also true of the mother's mental health. “Research 30 years ago was mainly focused on postnatal depression and its impact on the mother and her child. Then we realised antenatal depression (depression during pregnancy) is as important, as is chronic depression across the life course," Tomlinson stated.

No full inoculation against adversity

 As a result, there's been a worldwide push for a focus on, and investment in early-childhood interventions. This has been hugely successful. It is, however, important to remember that nothing can completely “inoculate" a child against developmental disruption. “We've found that interventions sometimes have small positive impacts, and that impacts sometimes 'wash out' over time (i.e. become invisible in the long run). Sometimes, they fade and then re-emerge later," says Skeen. “One can't expect just one short programme in the early years to change the outcomes of people's lives, especially in conditions of extreme poverty."

Continued investment is needed – including, and perhaps particularly, in adolescence. “While brain development is incredibly fast, with lots of synapse pruning in those first 1 000 days, we now know that an enormous amount of brain development also happens in adolescence," says Tomlinson.

Current research suggests that certain adolescent interventions are particularly successful, especially those focusing on interpersonal skills and emotional regulation. However, such findings have come mostly from high-income countries. The challenge is to adapt these interventions for use in low-income settings. The ILCHR is working with the WHO on guidelines for such programmes and exploring targeted prevention measures for adolescents at risk of depression and anxiety, substance abuse, aggression and self-harm.

 Building a foundation for later interventions

The ILCHR is also doing important work in testing interventions for younger children, including the Mphatlalatsane study in Lesotho and the Philani and Thula Sana (“Hush Baby") randomised controlled trials in South Africa. All have involved community health workers making home visits to mothers during pregnancy and during their children's early years.

The Mphatlalatsane study, completed in 2018, focused on a group-based intervention on nutrition, HIV testing and language development. The Philani study is tracking the impact of a home visiting programme run by a non-governmental organisation in Khayelitsha. During the Thula Sana trial, the ILCHR tracked children for the first eighteen months of life, again at 13 years, and then later re-enrolled the group into an intervention for adolescents. Tomlinson explains: “We're trying to determine when interventions are most effective: Does a second intervention at age 17 give a significant reinforcing boost to an early intervention implemented in the first six months?"

 Challenges of long-haul research

 Life-course studies can be expensive and time consuming: Thula Sana has run for 18 years; the Philani study has lasted eight years. They're logistically tough as well – data collectors sometimes need four wheel drives or even donkeys to access rural villages in the Eastern Cape and Lesotho. The work is also conceptually challenging. Mental health is difficult to measure, as are adversity, violence and poverty.

Finally, there are many different factors that may or may not have an effect, depending on the individual child and specific environment concerned. Some children struggle when faced with “the smallest environmental insult … but if that same child were in a really good environment, they'd thrive," Tomlinson concludes.

* This article featured in the latest edition of Stellenbosch University (SU)'s  multi-award winning publication Research at Stellenbosch University . Produced annually by SU's Division for Research Development (DRD), this flagship publication offers the national and international research community as well as other interested parties a comprehensive, yet accessible overview of innovative and interesting research being done at the institution.The theme of the edition is Research for Impact which is one of SU's core strategic themes from its Vision 2040 and Strategic Framework 2019–2024.

Click here to access the virtual copy.  ​